Based on an analysis of 122 breakthrough infections, American researchers conclude that timely and correct administration of post-exposure prophylaxis is crucial to prevent rabies. In more than half of the cases, the guidelines were not followed. While people with high-risk exposures or immune suppression can develop rabies despite following guidelines, this is rare.
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Post-exposure prophylaxis (PEP) for rabies is very effective in preventing a fatal outcome. Nevertheless, sporadic breakthrough infections are reported. US researchers conducted a systematic review of papers published between 1980 and 2022 to characterize these breakthrough infections. After reviewing 3380 articles, 52 were selected, describing a total of 122 breakthrough infections. These were classified based on compliance with guidelines (wound cleaning and vaccine administration). Of the 86 breakthrough infections with data on this, the median time from exposure to onset of symptoms was 20 days (IQR 16-24). Most participants (89 of 115, 77%) received PEP within 2 days of exposure. Serious wounds (multiple wounds or bites to the head, face or neck) were common (80 of 116, 69%). Deviations from the guidelines were reported in 68 of 122 cases (56%). Other possible causes of breakthrough infections included errors in immune globulin administration, delays in seeing a physician, and comorbidities or immune suppression. Problems in the cold chain and the quality of the vaccine or immune globulin were assessed only rarely (8 of 122 cases, 7%) and were not found to be a cause of breakthrough infections.
Bron:
Whitehouse ER, Mandra A, Bonwitt J, et al. Human rabies despite post-exposure prophylaxis: a systematic review of fatal breakthrough infections after zoonotic exposures. Lancet Infect Dis. 2022 Dec 12. Online ahead of print.